GMCH 2019 Staff Nurse Solved Question Answers
Below are the previous year paper of Government Medical College & Hospital (GMCH) Question Paper with answer keys of Exam Name 'STAFF NURSE GR II' And exam conducted in the year 2019. And question booklet series is B'. The question paper medium was in english . The answer key is given below but we suggest you try to question the answer yourself and compare the keys to check your performance. Because we want you to do practice yourself.
PART — I
1. Arrange the following five events in correct order of occurrence:
I. Stimulation of anterior pituitary
II. Stimulation of ovaries
III. Stimulation of neurosecretory cells
IV. Release of Gonadotropic hormone
V. Release of Gonadotropin releasing hormone
Codes :
A) III, V, I, IV, II
B) II, IV, I, V, III
C) I, V, III, II, IV
D) IV, V, III, II, I
2. Arrange the following events in the order of their occurrence in Panic circle :
I. Apprehension or worry
II. Body sensations
III. Perceived threat
IV. Interpretation of sensations as catastrophic
V. Trigger stimulus
Codes :
A) I, III, II, V, IV
B) V, II, III, I, IV
C) V, III, I, II, IV
D) III, V, I, II, IV
3. While receiving blood transfusion the patient develops chills and headache. What should be the nurses initial action?
A) Notify the physician STAT
B) Stop the transfusion immediately
C) Cover the patient with a blanket and administer ordered acetaminophen.
D) Slow the blood flow to keep the vein open.
4. Choose the most therapeutic response to Mr. Shyam's question: "Am I going to die?"
A) "We all are going to die one day."
B) "What has your doctor told you?"
C) "You really don't want to talk about death, do you?"
D) "Would you like to talk about your condition and prognosis?"
5. Which of the following would be a common indication of infiltration of a peripheral intravenous infusion?
A) Redness and swelling around the insertion site
B) Blood return in the cannula
C) Difficulty regulating the flow with gravity
D) Cool skin distal to the insertion site
6. Ms. Babita is in the emergency room after being involved in a traffic accident. What would be an early sign of hemorrhagic shock?
A) Increased blood pressure
B) Pallor
C) Increased pulse
D) Deep breathing
7. Ms. Anita asks the nurse when she can start eating after surgery. What is the most appropriate response by the nurse?
A) "You'll have to ask the doctor."
B) "Tell me about your appetite."
C) "You'll likely start on clear fluids once bowel sounds can be heard."
D) "I'll have the dietitician consult with you about the most nutritious post surgery menus."
8. When caring for an infant during cardiac arrest, which pulse must be palpated to determine cardiac function?
A) Carotid
B) Brachial
C) Pedal
D) Radial
9. The evidence to assert, whether or not, experimental treatment/condition has made the difference refers to:
A) External validity
B) Internal Validity
C) Criterion validity
D) Construct validity
10. Which nursing theorist believes that most patients are capable of performing self care?
A) Dorothea Orem
B) Madeleine Leininger
C) Martha Rogers
D) Sister Callista Roy
Previous year question Paper of GMCH 2019
11. What is the term used for normal respiratory rhythm and depth in a client?
A) Eupnea
B) Apnea
C) Bradypnea
D) Tachypnea
12. Alarm, resistance, and exhaustion are concepts related to
A) Health Belief Model
B) Trans theoretical Model
C) Health Promotion Model
D) General Adaptation Syndrome
13. A client is in the late active phase of labour. Suddenly she tells the nurse she feels weak and dizzy. The nurse notes the drop in maternal B.P. and late decelerations of fetal heart rate. The initial action the nurse should be to
A) Increase the I.V. drip rate and notify the provider
B) Turn the client on side and administer oxygen
C) Assess for cord prolapse or vaginal bleeding
D) Prepare for immediate delivery
14. During which war did the United States ask for Florence Nightingale's assistance in setting up military hospitals?
A) Crimean War
B) World War I
C) World War II
D) Civil War
15. Birth rate is-
A) Live birth/1000 mid-year population
B) Birth/ 1000 mid-year population
C) Live birth/ 10000 mid-year population
D) Live birth/ 10000 population of reproductive age Group (15-45 year)
16. As per latest census sex ratio (the number of females per 1000 of males) of Chandigarh is reported to be
A) 718
B) 818
C) 918
D) 1000
17. This step of the nursing process includes the systematic collection of all subjective and objective data about the client in which the nurse focuses holistically on the client- physical, psychological, emotional, sociocultural, and spiritual aspect.
A) Assessment
B) Planning
C) Implementation
D) Diagnosis
18. There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor?
A) Obesity
B) Heredity
C) Gender
D) Age
19. When administering single rescuer adult CPR, what is breaths-to-compressions ratio?
A) 2 breaths every 30 compressions
B) 1 breath every 30 compressions
C) 1 breath every 15 compressions
D) 2 breaths every 5 compressions
20. Rashtriya Bal Swasthya Karyakram (RBSK) is a new initiative aiming at early identification and early intervention for children from birth to 18 years to cover 4 `D's viz.
A) Defects at birth, Deficiencies, Diseases, Development delays including disability.
B) Drug Abuse, Deficiencies, Development delays including disability and Defects at birth.
C) Deformities, Development delays including disability, deficiencies and drug abuse
D) Diseases, Development delays including disability, defects at birth and diarrhoeal diseases
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21. A positive over-the-counter pregnancy test is considered a:
A) Possible sign of pregnancy
B) Presumptive sign of pregnancy
C) Probable sign of pregnancy
D) Positive sign of pregnancy
22. You are working in a paediatric unit of the hospital and caring for a six year old boy who is hospitalized with cystic fibrosis and respiratory compromise. Which developmental task is the challenge for this boy at his age?
A) To cough, deep breathe and improve respiratory status
B) To establish industry and self confidence
C) To develop autonomy and self control
D) To develop initiative and a sense of purpose
23. During which week does the fetal heart begin pumping its own blood?
A) 3"I week
B) 4th week
C) 5th week
D) 6th week
24. Which type of cancer has the poorest prognosis?
A) Squamous cell carcinoma
B) Breast cancer
C) Pancreatic cancer
D) Gastric cancer
25. The stages of infection in correct sequential order are:
A) The prodromal, incubation, illness and convalescence stages
B) The incubation, prodromal, illness and convalescence stages
C) The prodromal, primary infection , secondary infection and tertiary infection
D) The inflammation, infection and disease
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26. Match List — I with List — II and give your answer using the codes given below :
List I List II
(Neuron systems) (Areas of Brain)
p. The acetylcholinergic system 1. Raphe nuclei
q. The noradrenergic system 2. Lateral hypothalamus
r. The serotonergic system 3. Pons and basal forebrain
s. The hypocretinergic system 4. Locus coeruleaus
Codes :
p q
A) 1 2 3 4
B) 3 1 4 2
C) 4 3 1 2
D) 3 4 1
27. Which of the following is the best method to relieve constipation during pregnancy?
A) Lying flat on the back while sleeping
B) Increasing the intake of vegetables and fruits
C) Reduction of iron intake by half
D) Taking a mild over-the-counter laxative
28. Of the following, which disease causes most death worldwide?
A) Cardiovascular disease
B) HIV/AIDS
D) Tuberculosis
C) Malaria
29. Which of the following is a vector of infection?
A) An infectious fly
B) A contaminated thermometer
C) A contaminated ball
D) An infected person
30. An infant born with non communicating hydrocephalus has just had a ventro peritoneal shunt inserted. In addition to neuromuscular assessments what measures should the nurse use in child's care plan?
A) Reinforce wet dressings every 2 hourly
B) Position the infant on operative side
C) Place infant in semi fowlers position
D) Measure head and abdominal circumference
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31. Select the anatomic malformations associated with the Tetralogy of Fallot.
A) Ventricular septal defect, an overriding aorta, right ventricular hypertrophy,
pulmonay stenosis
B) Atrial septal defect, an overriding aorta, right ventricular hypertrophy, pulmonary stenosis
C) Ventricular septal defect, an overriding aorta, left ventricular hypertrophy, and right ventricular outflow
D) Atrial septal defect, an overriding aorta, pulmonary atresia, and right ventricular outflow
32. Which of the following conditions is related to the development of renal calculi?
A) Pancreatitis
B) Fractured femur
C) Gout
D) Disc disease
33. Select the cranial nerve paired with its name correctly.
A) The twelfth cranial nerve: The hypoglossal nerve
B) The fifth cranial nerve: The auditory nerve
C) The second cranial nerve: The olfactory nerve
D) The tenth cranial nerve: The trigemminal nerve
34. What could be the expected delivery date for the woman who got her last menstrual cycle on 20th Apri1,2018?
A) January 27th 2019
B) February 20th 2019
C) January 31s`2019
D) February 27'112019
35. A 4-year-old female child suffered severe burns in a house fire. How will you examine the extent of her burns?
A) By using the Parkland Formula
B) By using the Lund and Browder chart
C) By using the Hartman's formula
D) By using the Rule of Tens
36. A female client who has just been diagnosed with hepatitis A asks, "How could I have got this disease?" What is the nurse's best response?
A) "You may have eaten contaminated restaurant food."
B) "You could have gotten it by using I.V. drugs."
C) "You must have received an infected blood transfusion."
D) "You probably got it by engaging in unprotected sex."
37. Select the criterion that is coupled with its indication of gestational age or birth weight.
A) Small for gestational age: The neonate's weight is less than 20th percentile
B) Large for gestational age: The infant's weight is above 99th percentile
C) Low birth weight: The infant's weight is less than 1,500g at the time of delivery
D) Appropriate for gestational age: The neonate's weight lies in the range of 10th to 90th percentile
38. Which of the following is paired correctly with its description about skeletal fracture?
A) An avulsion fracture: A fracture that extracts a part of bone from the ligament or tendon
B) A greenstick fracture: This bends the bone but does not lead to a fracture
C) A complete fracture: The fractured bone pierces to the skin surface through the skin
D) A pathological fracture: A fracture that occurs due to some physical trauma
39. Which of the following signs and symptoms indicates salicylate toxicity ?
A) Chest pain
B) Pink coloured urine
C) Slow pulse rate
D) Ringing in ears
40. Urinary bladders is lined with?
A) Simple epithelium
B) Stratified epithelium
C) Transitional epithelium
D) Pseudostratified epithelium
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41. An emergency room nurse is assessing a 22 year old male who has been using opioids. What symptoms indicate that the client has overdosed?
A) Constricted pupils and hypotension
B) Vomiting and tachypnoea.
C) Pupillary dilatation and hypertensive crisis
D) Tremors and ataxia.
42. Which of the .following pairs is not the negative symptom of Schizophrenia?
A) Emotional flattening and Asociality
B) Anhedonia and amotivation
C) Poverty of speech and apathy
D) Hallucinations and Bizarre behaviour
43. The nurse is providing a teaching session to a client who has ulcerative colitis. The nurse will instruct the client for which diet?
A) Carbohydrate-consistent diet
B) High-calorie, high-protein diet
C) High-calcium and high potassium diet
D) Low-residue, low-fiber diet
44. Which of the following categories would a 70 year old adult be placed in?
A) Intimacy vs. Isolation
B) Generativitiy vs. Stagnation
C) Integrity vs. Despair
D) Longevity vs. Guilt
45. Furosemide acts on which part of the nephron?
A) Proximal tubule
B) Descending limb of the loop of Henle
C) Ascending limb of the loop of Henle
D) Distal tubule
46. A person with Schizophrenia was found to repeat whatever words the psychiatric nurse was speaking. This behaviour can be labelled as :
A) Echopraxia
B) Neologism
C) Word Salad
D) Echolalia
47. After falling from a 10 feet ladder, a patient is brought to the emergency department. The patient is alert, reports back pain, and difficulty moving the lower extremities. Which additional observation is an indication the patient may be experiencing neurogenic shock?
A) Cool and pale skin
B) Bradycardia
C) Poor skin turgor
D) Increased systolic blood pressure
48. The nurse should instruct a patient who is to receive digoxin (Lanoxin) to report development of which of the following side effects?
A) Ringing in the ears
B) Alopecia
C) Signs of bruising
D) Sensitivity to sunlight
49. Match List — I with List — II and indicate your answer with the help of the codes given below :
List — I List — II
p) Number of new cases that occur over a given period of time. 1.Epidemiology
q) Study of the distribution of diseases or health related 2. Syndrome
behaviours in a given population
r) Number of cases in a population in a given period of time. 3. Incidence
s) A group or cluster of symptoms that occur together. 4. Prevelance
Codes:
p q r s
A) 2 1 3 4
B) 4 2 1 3
C) 3 1 4 2
D) 1 4 3 2
50. Which of the following does not describe an obsession?
1. Continually reliving a traumatic event.
2. An unwanted thought that a person finds intrusive and distressing.
3. A behaviour that a person feels compelled to perform.
4. Something a person enjoys doing and talking about constantly. Codes :
A) 1, 2 and 4
B) 2 and 4
C) 2, 3 and 4
D) 1, 3 and 4
51. Given below are the three types psychological investigations : (1) Field experiments,
(2) Laboratory experiments, and (3) Ex post facto field studies.
If the above investigations are arranged in descending order in terms of researcher's ability to control secondary variance, the typical order would be:
A) 2, 1, 3
B) 3, 1, 2
C) 2, 3, 1
D) 3, 2, 1
52. World Health Day is observed on
A) 7th April
B) 8th May
C) 9ch June
D) 10th July
53. A patient presents to the emergency department with a blood pressure of 180/130 mmHg, headache, and confusion. Which additional finding is consistent with a diagnosis of hypertensive emergency?
A) Retinopathy
B) Bradycardia
C) Jaundice
D) Urinary retention
54. Which of these assessment findings should the nurse expect to identify as an early clinical characteristic of multiple sclerosis (MS)?
A) Dementia
B) Muscle atrophy
C) Vision loss
D) Clonus
55. A patient who has a history of chronic bronchitis is admitted to the medical unit. The nurse notes the red blood cell count is elevated. Which of these is the likely contributing factor to this lab result in this patient?
A) Chronic hypoxia
B) Hypercapnia
C) Decreased fluid intake
D) Insensible water loss
56. A patient has recently been diagnosed with leukemia. Which of the following symptoms would a nurse expect to see given this diagnosis?
A) Bruising, fatigue, and bone pain
B) Bradycardia, hypotension, and palpitations
C) Paresthesia, facial rash, and abdominal pain
D) Dyspnea, malaise, and hypotension
57. A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation of this lung field, the nurse would expect to hear which breath sound?
A) Rhonchi
B) Stridor
C) Crackles
D) Wheezes
58. The nurse anticipates the following laboratory study to assess the therapeutic effect in the client taking heparin intravenously:
A) Prothrombin time
B) Activated partial thromboplastin time
C) Hematocrit
D) Hemoglobin
59. A nurse performs pre operative teaching for a client who is to have a cataract surgery. Which is most important instruction for the client she should render ?
A) Remain flat for 3 hours
B) Eat a soft diet for 2 days
C) Breathe and cough deeply
D) Avoid bending from the waist
60. Which of the following is not a potential source of acquired immunity?
A) Antibodies received in response to disease
B) Antibodies received from the mother
C) Prescribed multivitamins
D) Animal serum
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61. When teaching the care givers of a patient who has dementia of the Alzheimer type, a nurse should stress the importance of
A) Increased stimuli
B) Predictable environment
C) Restricted activities
D) Independent decision making
62. Which of the following describes the cognitive triad of depression?
A) Helplessness, sleeplessness, worthlessness
B) Thoughtlessness, worthlessness, sleeplessness
C) Hopelessness, worthlessness, thoughtlessness
D) Hopelessness, worthlessness, helplessness
63. A 65-year-old patient with pneumonia is receiving garamycin (Gentamicin). It would be most important for a nurse to monitor which of the following laboratory values in this patient?
A) Hemoglobin and hematocrit
B) Blood Urea Nitrogen and creatinine
C) Platelet count and clotting time
D) Sodium and potassium.
64. A man is admitted to the Telemetry Unit for evaluation of complaints of chest pain. Eight hours after admission, the patient goes into ventricular fibrillation. The physician defibrillates the patient. The nurse understands that the purpose of defibrillation is to:
A) Increase cardiac contractility and cardiac output
B) Cause asystole so the normal pacemaker can recapture
C) Reduce cardiac ischemia and acidosis
D) Provide energy for depleted myocardial cells
65. A perception that occurs when a sensory stimulus is present but is incorrectly perceived and misinterpreted is known as:
A) Hallucination
B) Delusion
C) Illusion
D) Neologism
66. What is the age limit approved in COTPA bill for the sale of tobacco products and cigarettes in approved packaging?
A) 16 years
B) 18 years
C) 21 years
D) 25 years
67. A nurse is giving instructions to a client receiving lithium citrate. The nurse tells the client to do which of the following to prevent lithium toxicity:
A) Avoid becoming dehydrated during exercise
B) Instruct the client to change positions slowly
C) Restrict salt intake in the diet
D) Limit fluid intake
68. DOTS stands for
A) Direct Observation Treatment Short course
B) Differential Observation Treatment Short course
C) Direct Observation Treatment Scheme
D) Direct Observation Treatment Survey
69. Which of the following is responsible for the spread of dengue?
A) Anopheles mosquito
B) Culex mosquito
C) Aedes mosquito
D) Housefly
70. Which of the following is true about the aim of sustainable development goals : goal 1:
A) Cut poverty by half in 2030
B) Reduce poverty by 75% by 2030
C) End poverty in all its forms everywhere
D) Help each nation make progress on reducing poverty
PART — II
71. The doctor orders Zofran (ondesteron HC1) 8 mg PO t.i.d. The pharmacy sends a 100 ml bottle, labeled 4 mg/teaspoon. How many ml should be given for each dose?
A) 2 ml
B) 8 ml
C) 5 ml
D) 10 ml
72. A patient who has experienced a stroke is being monitored during the acute management phase. The clinician notes that the patient's intracranial pressure (ICP) is 30mm Hg. Which of the following interventions should be taken first?
A) Give trendelenburg position to the patient
B) Obtain vital signs and measure urine output
C) Assess level of consciousness
D) Raise the head of the bed to 30°
73. A patient with a history of atrial fibrillation is scheduled for a left hip hemiarthroplasty at 09:OOAM The health professional is administering 08:00 am medications. Which of these medication orders should the nurse be concerned about?
A) Opioid analgesic intravenously
B) Low molecular weight heparin anticoagulant subcutaneously
C) Beta blocker orally
D) Cephalosporin antibiotic intravenously
74. The nurse is assisting a doctor with the removal of a central venous catheter. To prevent complications, the patient should be instructed to
A) Perform the Adsons maneuver while removing catheter
B) Perform the Valsalva maneuver as the catheter is pulled
C) Turn his head to the right while grasping the siderails
D) Turn his head to the left side and hyperextend the neck while looking up
75. During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the nurse. Which of the following should be the nurse's next action?
A) Ask the patient to perform a Valsalva maneuver
B) Obtain an order for a bladder scan
C) Assess femoral pulses
D) Measure the abdominal circumference
76. Which of the following are correct techniques while checking the blood pressure of a patient:
I. Before the measurement patient must remain in a sitting position for about 5 minutes.
II. The cuff must be at the level of the heart.
III. The arm must be freely hanging without any firm support
IV. The stethoscope must be placed a little above than the cuff.
A) I, II,IV
B) I, III,IV
C) I &II
D) II & IV
77. Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair?
A) Bend at the waist and place arms under the client's arms and lift
B) Face the client, bend knees and place hands on client's forearm and lift
C) Spread his or her feet apart
D) Stand at the back of patient and lift him/ her
78. During an arteriogram (angiogram), the patient suddenly says, "I'm feeling really hot." Which is the best response?
A) "You are having an allergic reaction to the dye. I will get an order for Benadryl."
B) "The heat indicates that the clots in the coronary vessels are dissolving."
C) "Let me check the room temperature"
D) "That feeling of warmth is normal when the dye is injected. It will last up to 20 seconds."
79. A nurse receives report on four clients admitted to the emergency room. Who should she assess first?
A) Client with cherry red skin who has been waiting 15 minutes
B) Client with a blood pressure of 180/76 on 2L of oxygen via NC
C) Client vomiting from a heroine overdose
D) Client with asthma receiving treatment from respiratory therapy
80. The healthcare provider is caring for a patient on a ventilator with an endotracheal tube in place. What assessment data indicate the tube has migrated too far down the trachea?
A) Decreased breath sounds on the left side of the chest
B) A high pressure alarm sounds
C) Increased crackles auscultation bilaterally
D) Low pressure alarm sounds
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81. When examining a patient with abdominal pain the nurse incharge should assess:
A) Any quardent first
B) The symptomatic quardrant first
C) The symptomatic quardrant last
D) The symptomatic quardrant either second or third
82. The nurse is caring for a patient with cervical cancer. The nurse notes that the cervical implant has become dislodged. Which of the following actions should the nurse take first?
A) Stay with the patient and contact radiology
B) Wrap the implant in a blanket and place it behind the lead shield
C) Obtain a dosimeter reading on the patient and report it to the physician
D) Pick up the implant with long-handled forceps and place it in a lead container
83. A 68 year old women diagnosed with thrombocytopenia due to acute lymphocytic leukemia is admitted to the hospital. The nurse should assign the patient to:
A) To a private room so she will not infect other patients and health care workers
B) To private room so she will not be infected by other patients and health care workers
C) To a semiprivate room so she will have stimulation during her hospitalization
D) To a semiprivate room so she will have the opportunity to express her feelings about her illness
84. Which nursing action is essential when providing continuous enteral feeding?
A) Elevating the head of the bed.
B) Positioning the patient on left side
C) Warming the formula before administering it
D) Hanging the formula for 8 hrs in the beginning of morning shift
85. Which one of the following is the correct formula for calculating a person's body mass index (BMI)?
A) Weight in Kg x height in metres
B) Weight in Kg divided by height in metres squared
C) Weight in Kg divided by height in metres
D) None of the above
86. Which action by the nurse incharge is essential when cleaning the area around a Jackson- Pratt wound drain?
A) Cleaning from the center outward in a circular motion
B) Cleaning from periphery towards centre in circular motion
C) Cleaning briskly around the site from left to right
D) Cleaning briskly around the site from right to left
87. A patient is to receive 3,000 ml of 0.9% NaC1 IV in 24 hours. The intravenous set delivers 15 drops per milliliter. The nurse should regulate the flow rate so that the patient receives how many drops of fluid per minute?
A) 21
B) 28
C) 31
D) 42
88. Nurse can minimize agitation in a disturbed client by:
A) Increasing stimulation
B) Limiting unnecessary interaction
C) Increasing appropriate sensory perception
D) Ensuring constant client and staff contact
89. Physical assessment is being performed by a nurse. During the abdominal examination, nurse should perform the four physical examination techniques in which sequence:
A) Auscultation immediately after inspection and then percussion and palpation
B) Percussion, followed by inspection, auscultation, and palpation
C) Palpation of tender areas first and then inspection, percussion, and auscultation
D) Inspection and then palpation, percussion and auscultation
90. A client has just returned to a nursing unit after a cardiac catheterization performed using the femoral artery. The nurse places the client in which position?
A) Bed rest with head elevation at 30°
B) Bed rest with head elevation at 45°
C) Bed rest with head elevation at 60°
D) Bed rest with head elevation at 90°
91. After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first.
1. Constipation
2. Anticipated grieving
3. Ineffective airway clearance
4. Ineffective tissue perfusion.
A) 3,4,2,1
B) 4,3,2,1
C)1,3,2,4
D) 3,4,1,2
92. You come upon an unconscious victim with a palpable pulse. He do not appear to be breathing. You are unable to deliver the first breath. What is the next step?
A) Begin CPR
B) Repeat the head tilt/chin maneuveur and attempt the breath again
C) Abdominal thrusts
D) Helminch maneuveur
93. A nurse is caring for a client who expresses active suicidal ideations. Which of the following should be the nurses' action?
A) Engage patient actively in ward activities so that patient does not talk more about suicide
B) Administer the anti depressant drugs to reduce suicidal thoughts
C) Teach JPMR exercises to patient to reduce suicidal thoughts via relaxation
D) Indulge patient in interaction on suicide related thoughts and actions
94. Where should you place the AED pads on an adult victim?
A) One under the left arm pit and one high on the right side of the chest
B) One under the right arm and one high on the left side of the chest
C) One under each arm pit
D) One in the centre of the back and one over the centre of the chest
95. A nurse is assessing a pregnant client for the presence of ballotment. To make this determination, the nurse does which of the following?
A) Ascultates for fetal heart sounds
B) Assesses the cervix for compressibility
C) Palpates the abdomen for fetal movement
D) Initiates a gentle upward tap on the cervix
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96. The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
A) Urinary output of 30 ml per hour
B) No complaints of thirst
C) Increased hematocrit
D) Good skin turgor around burn.
97. A nurse auscultates the heart of Anu, a 21-year-old female. Anne seeks a consultation for dizziness and easy fatigability. During assessment, the nurse identifies a mid-to-late systolic click followed with mid-to-late systolic murmur at the cardiac apex. The murmur gets louder when Anne stands up. Based on these findings, Anu is most likely considered for which of the following cardiac problems?
A) Aortic stenosis
B) Mitral valve prolapsed
C) Pulmonic stenosis
D) Mitral regurgitation
98. While doing the tracheal suctioning of a patient, the suction should be applied
A) Only when withdrawing the suction catheter
B) Only when inserting the suction catheter
C) Either during insertion or withdrawal, depending on when the patient coughs
D) Only if the patient coughs
99. A nurse gives a double dose of acetaminophen (Tylenol) to a client who only requires a single dose. What, if anything, must the nurse do?
A) Ask a colleague to help assess the client
B) Withhold the client's next dose of Tylenol
C) Report the error as soon as possible
D) Nothing, because this is an over-the-counter medication
100. Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
A) Maintain the drainage tubing and collection bag level with the patient's bladder
B) Irrigate the patient with 1% Neosporin solution three times a daily
C) Clamp the catheter for 1 hour every 4 hours to maintain the bladder's elasticity
D) Maintain the drainage tubing and collection bag below bladder level
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